Safety of cantharidin: a retrospective review of cantharidin treatment in 405 children with molluscum contagiosum

DDIT4/mTOR signaling pathway mediates cantharidin-induced hepatotoxicity and cellular damage

Background

Cantharidin (CTD) extracted from the traditional Chinese medicine Mylabris has significant therapeutic effects on various tumors. However, the high toxicity of CTD can cause serious liver damage, although the related molecular mechanisms remain unclear.

Methods

In this study, we established models of CTD-induced liver and L-O2 cell damage in mice in vivo and in vitro. Subsequently, liver function indicators were detected in mouse serum, while liver tissues were subjected to pathological and transmission electron microscopy observations. L-O2 cell activity was investigated using the CCK-8 assay, and the mRNA and protein expression of DNA damage-induced transcription factor 4 (DDIT4) in liver tissue and L-O2 cells was detected using qPCR, immunohistochemistry, and western blotting. Western blotting was also used to detect the expression levels of autophagy- and apoptosis-related proteins in liver tissue and L-O2 cells. After RNAi interference with DDIT4, Rap, and 3-MA treatment, autophagy and apoptosis of L-O2 cells were detected using western blotting, flow cytometry, transmission electron microscopy, and confocal microscopy.

Results

Following CTD exposure, the mouse liver showed significant pathological damage and an increase in autophagic lysosomes, while the vitality of L-O2 cells showed a significant decrease. CTD led to a significant increase in the mRNA and protein levels of DDIT4 in both liver tissue and L-O2 cells, as well as a significant increase in LC3-II, Beclin1, and Bax, whereas p-mTOR and Bcl-2 were significantly decreased. Following DDIT4 interference and 3-MA treatment, the levels of autophagy and apoptosis induced by CTD in L-O2 cells were reduced. After Rap treatment, both autophagy and apoptosis of CTD-induced L-O2 cells were significantly enhanced.

Conclusion

The molecular mechanism of CTD-induced toxicity in mouse liver and L-O2 cells is mainly through DDIT4/mTOR signaling pathway activation, leading to an increase in autophagy and apoptosis levels.

Shuganning Injection Suppresses Apoptosis for Protecting Against Cantharidin-Induced Liver Injury by Network Pharmacology and Experiment Validation

Cantharidin (CTD) is a compound of mylabris with antitumor activity, and CTD can potentially cause toxicity, especially hepatotoxicity. The classical Traditional Chinese Medicine prescription Shuganning injection (SGNI) exerts notable anti-inflammatory and hepatoprotective effects. However, the protective property and mechanism of SGNI against CTD-induced liver injury (CTD-DILI) have not yet been elucidated. To investigate the effective compounds, potential targets, and molecular mechanism of SGNI against CTD-DILI, network pharmacology combined with experiments were performed. This study found that SGNI could act with 62 core therapeutic targets, regulate multiple biological processes such as apoptosis, and oxidative stress, and influence apoptotic and p53 signaling pathways to treat CTD-DILI. Subsequently, HepaRG cell experiments demonstrated that SGNI pretreatment significantly increased the levels of GSH-Px and SOD, inhibiting the apoptosis induced by CTD. In vivo, according to H&E staining, SGNI can reduce the degeneration of hepatocytes and cytoplasmic vacuolation in mice exposed to CTD. Western blot analysis results indicated that SGNI pretreatment significantly suppressed the expressions of Caspase-3 and Bax while increasing the expression of Bcl-2. In conclusion, SGNI acted as a protective agent against CTD-DILI by inhibiting apoptosis.

New Developing Treatments for Molluscum Contagiosum

A large variety of treatments for molluscum contagiosum (MC) are available, but none are Food and Drug Administration (FDA) approved and there is no consensus on the optimal approach, mainly owing to a lack of high-level data. Physical modalities are widely used, but require repeated outpatient visits for administration, are painful and difficult to perform in children, and are associated with the possibility of residual scarring and post-inflammatory hypo- or hyperpigmentation. Two experimental topical drugs, a new standardized preparation of topical cantharidin, called VP-102, and a topical nitric oxide (NO)-releasing product containing berdazimer, called SB206, represent promising products that have been designed to overcome the limitations of current treatments. They have recently shown good results in terms of safety and efficacy in large cohorts of patients in phase III studies and have the potential to be the first FDA-approved therapies for the treatment of MC.

British Association for Sexual Health and HIV national guideline for the management of Genital Molluscum in adults (2021)

This guideline offers recommendations on diagnosis, treatment regimens and health promotion principles needed for the effective management of genital molluscum, including management of the initial presentation and recurrences. The Primary focus of the guideline is on infection which affects the genital area and has a sexual mode of transmission. This is an update to the guideline previously published in this journal in 2014.

Safety and Efficacy of VP-102, a Proprietary, Drug-Device Combination Product Containing Cantharidin, 0.7% (w/v), in Children and Adults With Molluscum Contagiosum: Two Phase 3 Randomized Clinical Trials

Question

What is the efficacy and safety of VP-102, a drug-device combination containing cantharidin, 0.7% (w/v), in individuals aged 2 years or older with molluscum contagiosum compared with vehicle?

Findings

In 2 identical phase 3 trials (Cantharidin Application in Molluscum Patients [CAMP-1 and CAMP-2]) with a total of 582 participants, topical application of VP-102 or vehicle every 21 days for a maximum of 4 treatments resulted in complete lesion clearance rates of 46.3% (CAMP-1) and 54.0% (CAMP-2) with VP-102 vs 18% (CAMP-1) and 13% (CAMP-2) with the vehicle. The most common adverse events were primarily mild to moderate and included application site vesicles, pain, and pruritus.

Meaning

The findings of these trials support the efficacy and safety of a proprietary cantharidin-based drug-device combination for treatment of molluscum contagiosum in children and adults.

Importance

Molluscum contagiosum (MC) is a common viral skin infection that primarily affects children. Cantharidin, a topical vesicant, has a long history of use for MC in compounded formulations, but the safety and efficacy of doses, regimens, and application methods have not been demonstrated in large-scale trials.

Objective

To determine the safety and efficacy of VP-102, a drug-device combination containing cantharidin, 0.7% (w/v), compared with vehicle in individuals with MC.

Design, Setting, and Participants

Two phase 3, randomized, double-blind, vehicle-controlled trials of identical design (Cantharidin Application in Molluscum Patients [CAMP-1 and CAMP-2]) were conducted in 31 centers across the US. A total of 528 individuals aged 2 years or older with MC participated. CAMP-1 was conducted from March 21 to November 26, 2018, and CAMP-2 was conducted from February 14 to September 26, 2018.

Interventions

Participants were randomized (3:2) to topical application of VP-102 or vehicle to all treatable lesions every 21 days until complete lesion clearance or up to 4 treatments.

Main Outcomes and Measures

The primary efficacy outcome was the proportion of VP-102–treated participants achieving complete clearance of all MC lesions (baseline and new) compared with those who received the vehicle at the end-of-study visit on day 84. Intent-to-treat analysis was conducted for the efficacy population. Secondary efficacy outcomes included the proportion of participants achieving complete clearance of lesions at days 21, 42, and 63. Safety outcomes included assessment of adverse events, including expected local skin reactions.

Results

Of the 528 participants enrolled, 527 received treatment (CAMP-1, n = 265; CAMP-2, n = 262). A total of 267 of 527 participants (50.7%) were male; mean (SD) ages for CAMP-1 and CAMP-2 were 7.5 (5.3) years and 7.4 (8.0) years for the VP-102 groups and 6.3 (4.7) years and 7.3 (6.7) years for the vehicle groups. Treatment with VP-102 demonstrated superior efficacy to vehicle in the percentage of participants with complete clearance of MC lesions at the end of the study visit for CAMP-1 (VP-102: 46.3% vs vehicle: 17.9%; P < .001) and CAMP-2 (VP-102: 54.0% vs vehicle: 13.4%; P < .001). Adverse events were observed in 99% (CAMP-1) and 95% (CAMP-2) of VP-102–treated participants and 73% (CAMP-1) and 66% (CAMP-2) of vehicle-treated participants. The most common adverse events included application site vesicles, pain, pruritus, erythema, and scab. Most adverse events were mild or moderate in severity.

Conclusions and Relevance

In the 2 phase 3 trials reported herein, VP-102 was statistically significantly superior to vehicle in achieving complete clearance of MC lesions at the end of the study visit in both trials, with adverse events that were generally mild to moderate and confined to application sites. These findings show that VP-102 is potentially an effective and safe treatment for MC, a common skin condition with no US Food and Drug Administration–approved treatments.

Trial Registrations

ClinicalTrials.gov Identifiers: NCT03377790 and NCT03377803

2020 European guideline on the management of genital molluscum contagiosum

Molluscum contagiosum is a benign viral epidermal infection associated with high risk of transmission. The guideline is focused on the sexually transmitted molluscum contagiosum. The diagnosis is clinical with characteristic individual lesions, termed 'mollusca', seen as dome-shaped, smooth-surfaced, pearly, firm, skin-coloured, pink, yellow or white papules, 2 - 5 mm in diameter with central umbilication. Dermoscopy may facilitate diagnosis. Therapeutic options are numerous, including physical treatments (cautery, curettage and cryotherapy), topical chemical treatments (e.g. podophyllotoxin and imiquimod) or waiting for spontaneous resolution in immunocompetent patients. In pregnancy, it is safe to use physical procedures (e.g. cryotherapy). Immunosuppressed patients develop severe and recalcitrant molluscum lesions that may require treatment with cidofovir, imiquimod or interferon. Patients with molluscum contagiosum infection should be offered to be screened for other sexually transmitted infections.

Hepatoxicity mechanism of cantharidin-induced liver LO2 cells by LC-MS metabolomics combined traditional approaches

Hepatotoxicity induced by Mylabris has been reported in both clinical and animal experiments. Cantharidin (CTD), the main active compound of Mylabris was responsible for the hepatotoxicity, which aroused widespread concern. However, the mechanism of CTD hepatotoxicity remained unclear. In this study, LO2 cells were exposed to two doses of CTD (6.25 and 25 μM) for 12 h, the levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) were measured. The metabolites in LO2 cells were profiled by LC-MS. Partial least squares discriminant analysis and orthogonal partial least squares discriminant analysis were used for screening potential biomarkers. The MetPA software was used for clustering and pathway analysis. Network pharmacology was used to predict the genes acted with potential biomarkers. Compared with the control group, the levels of ALT, AST, and LDH was significantly increased after CTD treatment. A total of 46 potential biomarkers for hepatotoxicity induced by CTD were identified. And downregulated potential biomarkers reflected the inhibitory effects of CTD toxicity on metabolism of LO2. Moreover, CTD-induced liver toxicity of LO2 cells is mainly related to three pathways: cysteine and methionine metabolism; glutathione metabolism; and glycine, serine, and threonine metabolism. Furtherly, the mRNA expression of CES2, DNMT1, NOS1, NOS3, S1PR2, and CES1 screened by network pharmacology were regulated by CTD. These studies provide valuable mechanistic insights into CTD-associated hepatotoxicity that will aid in the development of therapeutic prevention and treatment options for this liver disease.

Efficacy and Safety of Topical Cantharidin Treatment for Molluscum Contagiosum and Warts: A Systematic Review

BACKGROUND AND OBJECTIVE

Topical cantharidin is routinely used for the treatment of molluscum contagiosum and warts. The objective of this systematic review is to assess the efficacy and safety of topical cantharidin treatment for molluscum contagiosum and warts.

METHODS

We performed a systematic review of studies assessing topical cantharidin treatment of molluscum contagiosum or warts. We searched the databases of Cochrane, EMBASE, GREAT, LILACS, MEDLINE, and Scopus. Two authors performed the study selection and data extraction.

RESULTS

Twenty studies (1958-2018) met inclusion/exclusion criteria. Twelve studies assessed warts, and eight studies assessed molluscum contagiosum. Overall, 1752 patients were included (range 0.3-62 years; specified in 15 studies). Clearance rates with topical cantharidin for molluscum contagiosum were variable (range 15.4-100%). Significant clearance of warts with maintenance of clearance was demonstrated with topical cantharidin alone. Topical cantharidin in combination with podophyllotoxin and salicylic acid demonstrated efficacy for plantar warts (pediatric and adult; clearance rate range 81-100%; four studies had 100% clearance), with the majority clearing after a single treatment. Satisfaction with cantharidin therapy was high, especially in molluscum contagiosum. Pain (7-85.7%), blistering (10-100%), and hyper-/hypopigmentation (1.8-53.3%) were the most commonly occurring adverse effects with cantharidin treatment.

CONCLUSION

Topical cantharidin demonstrated clearance of warts, particularly in combination with podophyllotixin and salicylic acid, and modest benefit for pediatric molluscum contagiosum with good tolerability and safety.

Tratamento de Molusco Contagioso em crianças: uma revisão sistemática de literatura

Objetivo: Molusco contagioso é uma infecção cutânea, causada pelo Molluscipox vírus. Diante da inexistência de um tratamento específico, esta pesquisa tem como objetivo verificar, segundo a literatura recente, os melhores métodos de tratamento em crianças imunocompetentes. Métodos: Revisão sistemática de literatura realizada no PubMed, bem como no Lilacs, Scielo, Medline e demais bases de dados abrangidas na Biblioteca Virtual em Saúde (BVS), com publicações de 2010 a 2016. Para evitar viés, foram utilizadas recomendações do PRISMA. Critérios do Oxford Centre for Evidence-Based Medicine e do sistema GRADE foram usados para classificação do nível de evidência dos estudos. Resultados: Curetagem, laser pulsado de contraste, crioterapia, exérese cirúrgica, KOH 2,5%, 5% e 10%, ácido tricloroacétrico, combinação de ácido lático e ácido salicílico, tretinoína 0,05% apresentaram boa proporção de cura, facilidade de realização e tempo de resolução. Os métodos de injeção intralesional do antígeno da Cândida e da vacina MMR, dieta balanceada, óleo de Malaleuca alternifólia e Ingenol Mebutate 0,05% mostraram-se promissores. Entretanto, cantaridina e imiquimod 5% creme não foram recomendados. Conclusão: As evidências obtidas não permitem indicar um método preferencial. A escolha do método de tratamento deve ser individualizada. Recomenda-se realizar mais pesquisas voltadas para cultura do vírus.

Molluscum Contagiosum: Review and Update on Management

Molluscum contagiosum (MC) is an infectious dermatosis that commonly presents in children and immunocompromised individuals. Although lesions usually resolve spontaneously after several months, they can be symptomatic and cause psychosocial distress. We review the evidence underlying treatment methods available for MC lesions, including potassium hydroxide, salicylic acid, hydrogen peroxide, retinoids, cantharidin, cryotherapy, curettage, and pulsed dye laser to aid practicing dermatologists in therapy selection.

To Treat Molluscum Contagiosum or Not-Curettage: An Effective, Well-Accepted Treatment Modality

BACKGROUND/OBJECTIVES

Molluscum contagiosum (MC) is a common viral disease primarily affecting children. The objective was to compare the effectiveness of curettage as a treatment modality for MC with no treatment.

METHODS

We performed a retrospective study of 2,022 children with MC between 2008 and 2012. Epidemiologic, clinical, and treatment data, including effectiveness, safety, and satisfaction, were reviewed.

RESULTS

Fifty-six percent of the children were 2 to 5 years of age. The duration of the infection was 1 to 2 years for 51%, less than 1 year for 32%, and more than 2 years for 17% of the children. Seventy percent of the children were self-referrals; 86% had had a previous examination and 76% of those had been advised not to treat the infection. The disease was mild (22%), moderate (64%), or severe (14%). A total of 1,879 patients underwent curettage; 70% were cured after one treatment and 26% after two treatments. Satisfaction was high: 97% of children and parents.

CONCLUSION

Active treatment should be offered despite the fact that MC is self-limiting. Curettage in an appropriate setting is very effective, with high patient satisfaction and fast cure rates.

Treatment of warts and molluscum: what does the evidence show?

PURPOSE OF REVIEW

Warts and molluscum contagiosum are very common viral skin infections, usually presenting in childhood. Despite the large number of people affected by them, high-quality trials of treatment are few and treatment is often chosen on the basis of cost, convenience and tradition.

RECENT FINDINGS

Over recent years, two further trials of the most commonly used treatments for warts, salicylic acid and cryotherapy, have been performed and for molluscum contagiosum, there is growing evidence for the use of irritants. For both infections, there are new evaluations of immunological approaches to therapy.

SUMMARY

Strong, high-quality evidence for treatments used very frequently for warts or molluscum is still lacking, but recent publications have helped to strengthen or weaken belief in commonly used therapies and to add weight to the immunological approach to management.

Childhood skin and soft tissue infections: new discoveries and guidelines regarding the management of bacterial soft tissue infections, molluscum contagiosum, and warts

PURPOSE OF REVIEW

Pediatric skin and soft tissue infections (SSTIs) constitute a significant number of office-based pediatric visits. With SSTIs on the rise, it is not only important to effectively treat the individual, but to do so appropriately and cost-consciously. In this article, we highlight new research related to the treatment of bacterial skin infections, molluscum contagiosum, and cutaneous warts, with the goal of guiding pediatricians in their practice against these common skin conditions.

RECENT FINDINGS

Recent data supports the use of topical antibiotics for noncomplicated impetigo. Systemic antibiotics covering gram-positive cocci are recommended for complicated cases of impetigo and deeper nonpurulent SSTIs. Localized purulent bacterial SSTIs can be treated with incision and drainage alone but more systemic involvement warrants treatment with systemic antibiotics covering Staphylococcus aureus species, especially community acquired methicillin-resistant S. aureus. For the treatment of molluscum contagiosum, topical cantharidin has a high satisfaction rate among patients and providers. Potassium hydroxide solution is a potentially effective and cheap form of molluscum contagiosum treatment. Imiquimod, however, has an unfavorable efficacy and safety profile as a therapy for molluscum contagiosum. Regarding warts, high-risk human papilloma virus strains have been detected in cutaneous warts in children.

SUMMARY

The high-risk human papilloma virus vaccine may play a role in treating pediatric cutaneous warts in the future, and topical squaric acid dibutylester may effectively treat recalcitrant warts. Finally, both molluscum contagiosum and warts have a high rate of resolution after an extended period of time without any intervention.

Helminthes and insects: maladies or therapies

By definition, parasites cause harm to their hosts. But, considerable evidence from ancient traditional medicine has supported the theory of using parasites and their products in treating many diseases. Maggots have been used successfully to treat chronic, long-standing, infected wounds which failed to respond to conventional treatment by many beneficial effects on the wound including debridement, disinfection, and healing enhancement. Maggots are also applied in forensic medicine to estimate time between the death and discovery of a corpse and in entomotoxicology involving the potential use of insects as alternative samples for detecting drugs and toxins in death investigations. Leeches are segmented invertebrates, famous by their blood-feeding habits and used in phlebotomy to treat various ailments since ancient times. Leech therapy is experiencing resurgence nowadays in health care principally in plastic and reconstructive surgery. Earthworms provide a source of medicinally useful products with potential antimicrobial, antiviral, and anticancer properties. Lumbrokinases are a group of fibrinolytic enzymes isolated and purified from earthworms capable of degrading plasminogen-rich and plasminogen-free fibrin and so can be used to treat various conditions associated with thrombotic diseases. Helminth infection has been proved to have therapeutic effects in both animal and human clinical trials with promising evidence in treating many allergic diseases and can block the induction of or reduce the severity of some autoimmune disorders as Crohn's disease or ulcerative colitis. What is more, venomous arthropods such as scorpions, bees, wasps, spiders, ants, centipedes, snail, beetles, and caterpillars. The venoms and toxins from these arthropods provide a promising source of natural bioactive compounds which can be employed in the development of new drugs to treat diseases as cancer. The possibility of using these active molecules in biotechnological processes can make these venoms and toxins a valuable and promising source of natural bioactive compounds. The therapeutic use of helminthes and insects will be of great value in biomedicine and further studies on insect toxins will contribute extensively to the development of Biomedical Sciences.